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Medication management in older people: the MEMORABLE realist synthesis
- Authors:
- MAIDMENT I D, et al
- Journal article citation:
- Health and Social Care Delivery Research, 8(26), 2020, Online only
- Publisher:
- National Institute for Health Research
- Place of publication:
- London
Background: The number and proportion of older people in the UK are increasing, as are multimorbidity (potentially reducing quality of life) and polypharmacy (increasing the risk of adverse drug events). Together, these complex factors are challenging for older people, informal carers, and health and care practitioners. Objectives: MEMORABLE (MEdication Management in Older people: Realist Approaches Based on Literature and Evaluation) aimed to understand how medication management works and propose improvements. Design: A realist approach informed three work packages, combining a realist review of secondary data with a realist evaluation of primary interview data, in a theory-driven, causal analysis. Setting: The setting was in the community. Participants: Older people, informal carers, and health and care practitioners. Interventions: Studies relating to medication management and to reviewing and reconciling medications; and realist-informed interviews. Data sources: MEDLINE, CINAHL (Cumulative Index of Nursing and Allied Health Literature) and EMBASE were searched (all searched from January 2009 to July 2017; searched on 1 August 2017). Supplementary articles were identified by the Research Team. Data were also obtained through interviews. Review methods: Searches of electronic databases were supplemented by citation-tracking for explanatory contributions, as well as accessing topic-relevant grey literature. Following RAMESES (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) guidelines, articles were screened and iteratively analysed with interview data, to generate theory-informed (normalisation process theory) explanations. Results: Developing a framework to explain medication management as a complex intervention across five stages: identifying problem (Stage 1), starting, changing or stopping medications (Stage 3) and continuing to take medications (Stage 4), where older people, sometimes with informal carers, make individual decisions and follow routines that fit medication management into their day-to-day lives, engendering a sense of control. In getting diagnosis and/or medications (Stage 2) and reviewing/reconciling medications (Stage 5), older people and practitioners share decision-making in time-limited contacts: involving four steps – sense-making, relationships, action and reflection/monitoring (normalisation process theory); and conceptualising burden – through a detailed analysis of Stage 5, generating a theoretical framework and identifying five burden types amendable to mitigation: ambiguity, concealment, unfamiliarity, fragmentation and exclusion. Proposing interventions: risk identification – a simple way of identifying older people and informal carers who are not coping, at risk and who need appropriate help and support; and individualised information – a short, personalised record and reference point, co-produced and shared by older people, informal carers and practitioners that addresses the experience of living with multimorbidities and polypharmacy. Limitations: Few studies directly address the complexity of medication management as a process and how it works. Limitations included, having identified the overall complexity, the need to focus the analysis on reviewing/reconciling medications (Stage 5), the exclusion of non-English-language literature, the focus on non-institutionalised populations and the broad definition of older people. Conclusions: MEMORABLE explored the complexity of medication management. It highlighted the way interpersonal stages in the medication management process, notably reviewing/reconciling medications, contribute to the mitigation of burdens that are often hidden. Future work: Co-produced studies to scope and trial the two proposed interventions; studies to extend the detailed understanding of medication management, linked to burden mitigation; and a study to clarify the medication management outcomes wanted by older people, informal carers and practitioners. (Edited publisher abstract)
Fall-risk evaluation and management: challenges in adopting geriatric care practices
- Author:
- TINETTI Mary E.
- Journal article citation:
- Gerontologist, 46(6), December 2006, pp.717-725.
- Publisher:
- Oxford University Press
One third of older adults fall each year, placing them at risk for serious injury, functional decline, and health care utilization. Despite the availability of effective preventive approaches, policy and clinical efforts at preventing falls among older adults have been limited. In this article the authors present the burden of falls, review evidence concerning the effectiveness of fall-prevention services, describe barriers for clinicians and for payers in promoting these services, and suggest strategies to encourage greater use of these services. The challenges are substantial, but strategies for incremental change are available while more broad-based changes in health care financing and clinical practice evolve to better manage the multiple chronic health conditions, including falls, experienced by older Americans.
Keeping track
- Author:
- MISKELLY Frank
- Journal article citation:
- Journal of Dementia Care, 13(3), May 2005, pp.36-37.
- Publisher:
- Hawker
This article describes the installation and early results of a system for electronic tagging which is intended to provide a warning when people with dementia may be straying into danger.
“A game of two halves?” Understanding the process and outcomes of English care home closures: qualitative and quantitative perspectives
- Authors:
- GLASBY Jon, ALLEN Kerry, ROBINSON Suzanne
- Journal article citation:
- Social Policy and Administration, 53(1), 2019, pp.78-98.
- Publisher:
- Wiley
With care services increasingly delivered via a market there is always a risk that care homes could fail financially or struggle in terms of quality, ultimately having to close. When this happens, the received wisdom is that subsequent relocation can be detrimental to the health and well‐being of older residents (possibly even culminating in increased mortality). However, there is very little formal evidence in the United Kingdom (UK) or beyond to guide policymakers and local leaders when undertaking such sensitive work. Against this background, this article reports findings from an independent evaluation of what is believed to be the largest care home closure programme in the UK (and possibly beyond). This consisted of qualitative interviews with older people, families, care staff, and social work assessors during the closure process in one case study care home and one linked day centre, as well as self‐reported health and quality of life data for older people from 13 homes/linked day centers at initial assessment, 28 days after moving and at 12‐month follow up. The study is significant in presenting public data about such a contested topic from such a large‐scale closure process, in its focus on both process and outcomes, in its mixed‐methods approach, and in its engagement with older people, families, and care staff alongside the use of more formal outcome measures. Despite significant distress part‐way through the process, the article suggests that outcomes either stayed the same or improved for most of our sample up to a year after moving to new services. Care homes closures may thus be a “tale of two halves”, with inevitable distress during the closure but, if done well, with scope for improved outcomes for some people in the longer term. These findings are crucial for current policy and practice given that the risk of major closures seems to be growing and given that there is virtually no prior research on which to base local or national closure processes. While some of this research is specific to England, the underlying issue of care home closures and lessons learned around good practice will also apply to other countries. (Edited publisher abstract)
Levels, types, and predictors of family caregiver strain during hospice home care for an older adult
- Authors:
- TOWNSEND Aloen L., et al
- Journal article citation:
- Journal of Social Work in End-of-Life and Palliative Care, 6(1-2), January 2010, pp.51-72.
- Publisher:
- Taylor and Francis
- Place of publication:
- Philadelphia
This study investigated levels of physical, psychological, social, economic, and spiritual strain reported by family caregivers to older adults receiving hospice home care together with risk and protective factors that predict strain. The project and resulting instrument (Western Reserve Family Assessment Instrument) resulted from a multidisciplinary collaboration between academic researchers at Case Western Reserve University and hospice providers at Hospice of the Western Reserve. Structured interviews were conducted with 162 family caregivers providing care to patients aged 65 years or more newly admitted to hospice home care. Caregivers spanned a broad age range, with an average age in the early 60s, and they were predominantly female and Caucasian. Hierarchical multiple regressions revealed that caregivers’ age and race, hospice patients’ major illness (particularly cancer), caregivers’ appraisal of their situation, and resources were significant risk or protective factors for caregiver strain, although the predictors varied by type of strain and amount of strain. The discussion focuses on the importance of identifying family caregivers at risk of higher strain during hospice home care and implications for family caregiver interventions.
Predictors of high level of burden and distress in caregivers of demented patients: results of an Italian multicenter study
- Authors:
- RINALDI P., et al
- Journal article citation:
- International Journal of Geriatric Psychiatry, 20(2), February 2005, pp.168-174.
- Publisher:
- Wiley
Considerable suffering is experienced by carers of patients with dementia. Most existing studies do not consider the coexistence of subjective and objective aspects that cause, interacting to each other, this suffering. The authors: (1) define the high-risk group of caregivers on the bases of the scores obtained on the four scales evaluating burden, distress, depression and anxiety (BDDA) taken into account simultaneously and (2) evaluate risk factors related to the high level of BDDA. 419 elderly outpatients with dementia and their caregivers were enrolled. Patients were evaluated for their cognitive, neuropsychological and functional impairment and for comorbidity. Caregivers were evaluated with four scales for the assessment of burden, distress related to neuropsychological disturbances, depression and anxiety. Cluster analysis was used to identify the group with the High level of BDDA (HBDDA). By multiple logistic analysis, disability, specific behavioural disturbances of the patients as well as caregiver's age, type of relationship and living in the south of Italy were observed to be a major risk factor for HBDDA. The targeted use of scales specifically assessing BDDA of the caregiver and the identification of particular patient and caregiver characteristics are able to allow a precise and early definition of caregivers at high risk of burden and distress. This might be helpful in planning the correct social/clinical/rehabilitative approach.
Concepts of self-rated health: specifying the gender difference in mortality risk
- Authors:
- DEEG Dorly J. H., KRIEGSMAN Didi M. W.
- Journal article citation:
- Gerontologist, 43(2), June 2003, pp.376-386.
- Publisher:
- Oxford University Press
Purpose: This study addresses the question of how the relation between self-rated health (SRH) and mortality differs between genders. In addition to the general question, four specific concepts of SRH are distinguished: SRH in comparison with age peers, SRH in comparison with one's own health 10 years ago, and current and future health perceptions. For these concepts, the gender-specific risks of mortality were evaluated for a short and a longer follow-up period. Baseline and mortality data from the Longitudinal Aging Study Amsterdam (N = 1917, initial ages 55-85 years) were used. Mortality risks were evaluated in Cox regression models at 3 and 7.5 years of follow-up, both adjusted for age and for sociodemographic characteristics, indicators of functional and mental health, lifestyle, and social involvement. All SRH measures were scaled from 1 (positive) to 5 (negative). Baseline correlations between SRH concepts were similar for men and women. After 3 years, 12% of the men and 7% of the women had died; after 7.5 years, these percentages were 27 and 15, respectively. In fully adjusted models, current health perceptions predicted 3-year mortality in men (risk ratio of 1.33). At 7.5 years, mortality in men was predicted by current health perceptions and by SRH compared with age peers (risk ratios of 1.25 and 1.23, respectively). In women, no SRH concept predicted either 3-year or 7.5-year mortality. SRH was a predictor of mortality only in men, not in women. The gender difference showed most clearly at longer follow-up, in the SRH concept "comparison with age peers."
Differences between older men and women in the self-rated health-mortality relationship
- Author:
- BATH Peter A.
- Journal article citation:
- Gerontologist, 43(2), June 2003, pp.387-395.
- Publisher:
- Oxford University Press
The aims of this study were to examine differences between older men and women: in the ability of self-rated health to predict mortality, in the effect of different follow-up periods on the self-rated health mortality relationship, and in the relative importance of self-rated health and self-rated change in health in predicting mortality. By using data from the Nottingham Longitudinal Study of Activity and Ageing, the author assessed relationships between self-rated health and self-rated change in health and 4- and 12-year mortality in separate unadjusted and adjusted Cox proportional hazards regression models in men and women. The differences between men and women in the hazard ratios for poor self-rated health were not significant, although there were differences in the explanatory factors. The relationship between self-rated health and short-term and long-term mortality was explained by age and health among men. The relationship between self-rated health and short-term mortality was explained by age, physical and mental health, and physical activity among women. The relationship between self-rated health and long-term mortality was explained by age, physical health, and physical activity among women. The relationship between self-rated change in health and short-term mortality was explained by age among men and women. The relationship between self-rated change in health and long-term mortality was explained by age and physical health among men and women. Social engagement was an independent predictor of short- and long-term mortality among men and women in this study. The finding that low self-rated health was not an independent predictor of mortality among men or women, contrary to many, but not all, previous studies, may be related to differences in study design and/or across cultures. Further research investigating relationships between self-rated health and mortality and potential explanatory variables should analyze men and women separately and should consider the length of follow-up period. The benefits of individual physical and social activities in reducing mortality merit further investigation.
Are gender differences in the relationship self-rated health and mortality enduring?: results from three birth cohorts in Melton Mowbray, United Kingdom
- Authors:
- SPIERS Nicola, et al
- Journal article citation:
- Gerontologist, 43(2), June 2003, pp.406-411.
- Publisher:
- Oxford University Press
The purpose of this study was to assess whether there is an enduring gender difference in the ability of self-rated health to predict mortality and investigate whether self-reported physical health problems account for this difference. Cox models for 4-year survival were fitted to data from successive cohorts aged 75-81 years registered with a primary care practice in the U.K. Midlands surveyed in 1981, 1988, and 1993-1995. Self-rated health was consistently a stronger predictor in men (hazard ratio ; 95% confidence interval 2.1-3.5) than it was in women ( 1.5-2.4). Women surveyed in 1993-1995 were more likely than men to report problems that were disabling but not life-threatening, whereas men were more likely to report potentially life-threatening problems. However, these differences did not explain the association of self-rated health with mortality. More than half of those who reported a potentially life-threatening problem said that their health was good. Self-rated health is more strongly associated with mortality in men, but this is unlikely to be explained by differences in the nature of their physical health problems.
Does the NHS deserve a golden celebration
- Authors:
- HIRST Judy, WELLARD Sarah
- Journal article citation:
- Community Care, 9.7.98, 1998, pp.8-9.
- Publisher:
- Reed Business Information
As the NHS celebrates its 50th anniversary, the authors reflect on the service it offers and examines the experiences of vulnerable social groups.